Digital skills of health care professionals in cancer care: A systematic review

Background The digital transformation of healthcare enables new ways of working in cancer care directing attention on the digital skills of healthcare professionals. This systematic review aims to identify existing evidence about digital skills among health care professionals in cancer care to identify the needs for future education and research. Methods Database searches were conducted in PubMed, CINAHL, Web of Science, Scopus, Cochrane and ERIC to identify studies until March 2023. The inclusion criteria were digital skills of health care professionals in cancer care as described by themselves, other health care professionals, patients or significant others. The CASP tool was used for quality assessment of the studies. Data was analysed following inductive content analysis. Results The search produced 4563 records, of which 24 studies were included (12 qualitative, 10 quantitative, 1 mixed methods design and 1 strategy paper). Four main categories were identified describing HCPs’ required skills, existing skills and development areas of digital skills in cancer care: Skills for information technology, Skills for ethical practice, Skills for creating a human-oriented relationship and Skills for digital education and support. In development areas, one more main category, Skills for implementing digital health, was identified. Conclusion The digital skills of health care professionals in cancer care are multifaceted and fundamental for quality cancer care. The skills need to be assessed to provide education based on actual learning needs. The review findings can be used for education and research in this field.


Introduction
In recent years, cancer care has been increasingly complemented by digital technology, 1,2 including monitoring symptoms and facilitating adherence to treatment and care, promoting healthy lifestyles and user engagement with digital cancer services. 3The evidence supports the comparability of cancer care services produced digitally and in person in terms of patient satisfaction and effectiveness. 1 Although the research evidence on digitally produced supportive cancer care is limited, improvements have been achieved in health-related outcomes. 2][7] There are few definitions of digital skills, and skills can be seen as an attribute to digital competence. 8,9The overlap of the two concept definitions makes it challenging to describe digital skills.Skills in general means the ability to apply and use knowledge to complete tasks and solve problems. 10Digital skills refer to the ability to access, manage, understand, integrate, communicate, evaluate and create information safely and appropriately.Furthermore, domains such as device and software operation, problem-solving and career-related competencies have been recognised in digital skills framework. 11This review focuses on digital skills defined as actions that HCPs take to support the health and resources of people with cancer to provide quality digital cancer care services.Competence is a broader concept encompassing skills and referring to the proven ability to use knowledge and skills as well as to personal, social and methodological abilities in professional development. 10It comprises (a) information and data literacy, communication and collaboration, digital content creation, and safety and problem-solving, 9 (b) knowledge of digital technology, social and communication skills, and ethical considerations, 12 and (c) self-assessed competence, knowledge and attitudes towards the use of digital technologies. 13everal recommendations related to digital skills have been reported.The emphasis has been on enhancing opportunities for digitalisation in cancer care 7 and providing education, information and support digitally for people with cancer while maintaining confidentiality. 14Furthermore, HCPs need digital literacy, that is, abilities to use digital technologies to find, evaluate, create and communicate information, 12 as well as apply the knowledge gained from electronic sources to address health problems. 15In their work, HCPs also collect, utilise and make decisions about digital health data.This requires skills for secure data handling and sharing whilst respecting the rights of individuals. 16The Code of Conduct for mobile health apps focusing on privacy and consent aims to increase trust in mobile health apps. 17he challenges in digital skills in cancer care have focused especially on developing a trusting relationship and providing person-centred care in a humane way. 18erson-centred care requires identifying patients' willingness to use digital technology, evaluating patients' digital capabilities and incorporating patients' needs into digital cancer care services.However, how to conduct patient education in digital environments needs clarification. 19hallenges have also been related to physical examination and assessment of patients via digital tools 1 as well as ethical practice, such as respecting patients' privacy and confidentiality during the digital appointment. 20Recent studies assessing HCPs' digital skills indicated that majority of participants (n = 803) demonstrated basic level of digital competence, 8 whereas in low-income countries (n = 167) the level was relatively low. 21There is a research gap in assessing HCPs' current digital skills in cancer care, and no previous literature review has been reported on the subject so far.
The purpose of this literature review is to identify existing evidence of digital skills among HCPs in cancer care to identify needs for future education and research.The review was guided by the following research questions: 1. What are the digital skills of HCPs in cancer care? 2. How should the digital skills of HCPs be developed in cancer care?

Methods
This study adheres to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 22 and is registered with PROSPERO (CRD42023413979).

Eligibility criteria
Inclusion and exclusion criteria for the review are described in Table 1.We accepted studies published from the establishment of the databases until March 2023.

Information sources
A systematic literature search was conducted in collaboration with the researchers and Information Specialist to six databases to identify eligible studies: PubMed, CINAHL, Web of Science, Scopus, Cochrane and ERIC.Additionally, references cited in the study reports included in the systematic review were screened to identify additional studies.

Search strategy
The literature search was conducted with three main concepts and their synonyms: digitalisation, skills and search were limited to peer reviewed journals and English language (Supplementary File 1).The search strategy was validated by test searches and discussion in the research group.

Selection process
Records were imported to Covidence software that assisted with the screening process and duplicates were removed.First, the records were screened independently by two researchers of the research team (CC, HLK, HV, JP, LT, TF or VS) based on title and abstract according to the eligibility criteria (Table 1) and conflicts were resolved by a third reviewer.Second, full texts were screened independently by two researchers according to the eligibility criteria and conflicts were resolved by a third reviewer of the research team (AB, CC, FSR, HLK, HV, JP, LT or SM).

Data collection process
Data was collected as follows: (a) reference, year, country, (b) purpose, (c) method, (d) theoretical approach, variables or focus of the research, (e) participants, (f) data collection, (g) analysis method, (h) findings related to digital skills and (j) conclusions related to digital skills.Data extraction was conducted independently by two researchers (LT and JP) and disagreements were resolved in consultation with a third person of the research team (HV or HLK). 23

Data analysis
Purpose of the analysis was to describe HCPs' digital skills.Data comprised both qualitative and quantitative studies, and based on that, inductive content analysis was used. 24,25The coding of the content focused mainly on describing the manifest content of the literature.Since the studies did not actually assess HCP's digital skills, the analysis focused on the descriptions of digital skills in the results, discussion or conclusion sections of the studies.The analysis included five steps for each research question. 25First, the researchers familiarised themselves with the data by reading the texts.Second, data was divided into meaning units and abstracted into codes related to digital skills.Third, the content and context of the codes were compared with each other, and corresponding codes were grouped into sub-categories.Fourth, the sub-categories were compared with each other, and based on similarities and differences, main categories were formed.Main categories were named according to their content. 24,25inally, the main categories were compared with each other, and their names were refined.During the whole abstraction process, construction of sub-and main categories and decisions was made in consensus among the research team (LT, JP, HV and HLK).In reporting, study characteristics and findings were tabulated, and representative quotes were used for supporting the credibility of the findings. 24

Quality appraisal of the studies
Articles were assessed independently by two researchers (SM and CC).Disagreements were discussed until consensus was reached.For qualitative studies, a 10-item CASP scale (0-10) for qualitative studies was used 26 focusing on (a) validity of the study, (b) accuracy of the results and (c) transferability.For quantitative studies, a 12-item CASP scale (0-12) for cohort studies was used 27 focusing on (a) validity of the study, (b) internal validity of the results and (c) external validity.Items 6A, 6B, 7 and 8 were not applicable for included cross-sectional studies, they were thus omitted.When there was a 'No' for questions 1 and/or 2, the quality assessment was not completed with follow-up questions. 31Quality appraisal was used to demonstrate the methodological quality of the studies as it affects the validity of the findings of the review. 27

Results
Of the 4563 records identified a total of 24 studies met the inclusion criteria (Figure 1).

Quality appraisal results
In the CASP checklist for 13 qualitative studies (Supplementary File 2), most of the studies showed a clear statement of the aims of the research, the qualitative study design was adequate, the findings were clearly defined, data collection and analysis were adequately rigorous in nine of the studies, and nine of them were designed in an appropriate way to achieve the aims of the research.However, recruitment strategy was considered appropriate in only three studies, and study results were likewise defined as being transferred to different settings in only three studies.
In the CASP checklist for 11 cohort studies (Supplementary File 3), most of the studies clearly stated their research objective, but only four of the 11 studies recruited the study population according to the aims of the research, and most of them used a convenience sampling strategy.Due to a cross-sectional study design, none of the studies measured exposure prior to the outcome, considered potential cofounding variables nor had a long enough follow-up.All studies have good internal validity but none of them has enough external validity to implement the results into different settings.

Digital skills of health care professionals in cancer care
The digital skills are analysed based on descriptions in the Results, Discussion and Conclusion sections of the studies.In the analysis, we identified three themes: required and existing skills and development areas in digital skills of HCPs.The required skills were those that were identified as skills that HCPs need to have to provide digital services.Existing skills were those that studies found HCPs to already have.Development areas were digital skills that, according to studies, still need improvement.In each of these themes, the following four main content categories were identified: 1. Skills for information technology 2. Skills for ethical practice 3. Skills for creating a human-oriented relationship 4. Skills for digital education and support In addition, one main category, 'Skills for implementing digital health', was identified as development area of HCPs' digital skills.(Table 3).Of the main categories, 'Skills for information technology' consists of four subcategories, 'Skills for ethical practice' of three subcategories, 'Skills for Creating a human oriented relationship' of four sub-categories and 'Skills for digital patient education and support' of six sub-categories.However, not all the above sub-categories appear in every question considered.In addition, 'Skills for implementing digital health' comprises two sub-categories.Next, digital skills identified as required, existing and development areas are presented in more details.
Required skills for information technology comprise two sub-categories: using digital technologies 28,31 and technological preparing of digital appointments. 29,35,38,45,49sing digital technologies includes skills to find alternative ways to assess patients and operating various digital platforms. 28It also includes skills to integrate digital technologies into clinical practice, access the Internet and search and filter online information.In addition, it includes developing the content, functionality and design of online sources. 31he following quotation expresses the requirements for using digital technologies: The nurses need to know how to access the Web and how to search and separate good and bad sites. 31eparing digital appointment includes respecting the schedule, such as calling the patient at the agreed time and allocating sufficient time for the appointment. 38,49It also includes technological skills such as technology check, 45 setting the camera position and lighting for the digital appointment, 29 as well as predicting technical problems 29,35,45 : For FTF encounters, seating arrangements, chair height, and eye level can impact the dynamics of the interaction, while on video the emphasis should be on camera position, appropriate front lighting, and minimizing technical issues with plans for trouble-shooting. 29quired skills for ethical practice comprise two subcategories: protecting patients' privacy 45 and ensuring confidentiality 50 and patients' consent. 41Protecting patients' privacy includes ensuring the setting is appropriate for

Assessing digital health information
Assessing information sources and website quality, 31  Filtering relevant information from the databases.31 Providing HCPs information about the content and reliability of cancer-related websites, 47 Guiding HCPs' choices as to appropriate and safe digital health resources and system. 43

Accessing digital resources
Assisting patients to navigate digital health, 43 Adapting new technologies, 42,51 Reminding HCPs about updated guidelines, 37

Enhancing
HCPs' awareness of institutional e-resources 46

Ethical practice
Protecting patients' privacy Ensure appropriate setting for digital appointment. 45otecting patients' privacy during digital meetings.28,30   Ensuring confidentiality Protect patients' passwords. 50suring confidential conversation, 28   Accessing patients' information with their consent, 50 Participation of a third person in a digital meeting.41   Ensuring patients' consent Consent to digital appointment, 41   Consent to the presence of third parties, 41  Ask permission for recording, 41  Request in-person consultation (continued) Using a caring tone of voice and guidance. 34eveloping skills to establish a relationship, 34  Create an emotional connection with patients, 32 Maintaining a rapport. 30

Providing e-counselling
Lacking skills for providing e-counselling in 2012.36

Individualising education
Determining what type of meeting will best serve the patient for each care encounter, 35,38,43,49 Tailoring information for patients' characteristics.48

HCP-patient interaction
e-mailing with patients, 31 communicate with care and support, 34  Expressing oneself affectively digitally, 29 Expressing oneself effectively and affectively, 30 Assessing patient reported health information online, 31 Respecting the scheduled appointment times, 38  Connecting at unscheduled times.38 Having the necessary communication skills, 41,49 Keeping nuances during digital communication, 49  Using different digital media in communication, 29  Preserving the human component of interaction, 38 Showing facial expressions, 29,44,48 Being present with a caring tone of voice and guidance. 34ontinued) Table 3. Continued.

Required skills
Existing skills

Development areas
Providing information Set a common agenda for appointment, 45  Deliver the key information, 45  End appointment by summarising the main points and review next steps, 45 Information consulting.31

Obtaining necessary information
Receiving accurate information, 39  Reading patients' reaction to the information provided, 49  Assessing patients' condition remotely, 28,38 Performing a physical examination, 30,32  Encouraging patients to ask questions, 38,49 Checking patients' understanding. 44oviding support Encourage expression of patients' feelings, 45 Respond empathically to patient's emotions, verbally acknowledging support, 45 Acknowledge patient's emotional cues, 45

Implementing digital health guidelines
Ensuring the safety of digital technologies, 42,51 Creating frameworks for the development, adoption and regulation of AI technologies, 42 Complying with the law, 51 Ensuring person-centred practice guidelines.35  health information discussion. 45Confidentiality includes protecting patients' passwords during digital appointment 50 : To maintain patient confidentiality, which may be compromised using personal mobile phones, most participants suggested that the mobile applications should be password protected. 50suring patients' consent includes asking patients' permission for a digital appointment.In addition, it includes ensuring patients' consent to the presence of third parties, such as family members or health care workers, during the videoconferencing (VC).In addition, it includes permission for recording audio content or images, and option to request an in-person consultation instead of a digital one. 41equired skills for creating a human-oriented relationship comprise two sub-categories: adopting a personcentred approach 32,35,41,43,45 and building rapport. 34,35,45dopting a person-centred approach includes working with patients to create person-centred options and knowing patients as persons 35 : They (patients) appreciated being asked questions about their families, occupation, and things that brought them joy and appreciated the nurses remembering these. 35 also includes individualised care, that is, tailoring digital approaches to suit individual needs, 32,43 and considering patients' language difficulties, hearing impairments 35 and cultural background. 41Building rapport means a connection established with another person based on respect, acceptance, empathy and a mutual engagement. 36Required skills for building rapport includes making introductions as needed at the beginning of the appointment, 45 partnering with the patients to ensure their concerns are responded to, 45 communicating with patients in a caring way 34 and using a personal touch during the digital appointment. 35equired skills for digital patient education and support comprise three sub-categories: providing information, 31,45 ensuring understanding and providing support. 45Providing information includes setting a common agenda for the appointment, delivering the key information and ending the appointment by summarising the main points and reviewing the next steps. 45It also includes information consulting for patients. 31Ensuring patients' understanding includes providing information in a structured way 45 and encouraging patients to participate. 45,49Furthermore, it includes using silence to help patients process information and checking patients' understanding 45 : Checking a patient's current understanding of the reason for the visit can help the clinician structure the conversation and fill in knowledge gaps when appropriate. 45oviding support includes encouraging expression of patients' feelings, responding empathically to patient's emotions or experiences and verbally acknowledging support.It also includes acknowledging patient's emotional cues and affecting patient's emotional responses during the digital appointment 45 : Pay attention to emotional cues from the patient during your visit, such as fidgeting, tuning out, crying, or looking very worried.Verbally acknowledge these cues during the visit. 45isting digital skills of health care professionals in cancer care Existing digital skills of HCPs are based on descriptions by HCPs themselves, 31,33 patients, 38 or both HCPs and patients. 34,35Existing digital skills of HCPs comprise three main categories: skills for (a) information technology, 31,33 (b) creating a human-oriented relationship 34,35,38 and (c) digital patient education and support [29][30][31]34,38,40 (Table 3).
Existing skills for information technology comprise two sub-categories: using digital technologies 31,33 and assessing digital health information. 31Using digital technologies includes work-based computer skills, such as to access online clinical sources and patient outcomes. 33It also includes actively searching information from databases for both HCPs and patients. 31Assessing digital health information includes assessing information sources and website quality.In addition, it includes filtering relevant information from databases. 31xisting skills for creating a human-oriented relationship comprise one sub-category, skills for building rapport, 34,35,38 which includes skills to adapt a bedside manner during VC, 35 being patient 38 and using a caring tone of voice and guidance 34 : Most (patients) felt that providers were very patient during the call, never rushed through questions, and were respectful of scheduled appointment times. 38isting skills for digital patient education and support comprise two sub-categories: HCP-patient interaction, [29][30][31]34,38 and providing online support. 40 HC-patient interaction includes skills for e-mailing with patients, for example, in relation to laboratory results and prescription renewals.31 It also includes communication with care and support. 34HCPs reported having skills to express themselves, both effectively 30 and affectively 29 : From individual statements (n = 28), 19 learners (68%) felt comfortable communicating using telehealth, and 21 learners (75%) indicated that they could express their emotional responses via VMC. 29 addition, HCP-patient interaction includes skills to assess patient-reported health information online. 31urthermore, it includes skills for respecting the scheduled appointment times and connecting even at unscheduled times. 38Providing online support includes skills for being a facilitator in a digital group chat by acting as a group leader, setting norms, building group cohesion, pacing discussion, using emotional self-disclosure, managing intense emotions and using online tools to enhance group objectives. 40e development areas of digital skills of health care professionals The development areas of HCPs' digital skills are based on descriptions by researchers, 28,31,37,39,41,43,44,48 HCPs themselves, 29,30,[32][33][34][35]42,46,47,50,51 or patients. 38,49 The deveopment areas for digital skills formed five main categories: improving skills for (a) information technology, 33,37,41- 43,46,47,51 (b) ethical practice, 28,30,41,50 (c) creating a human-oriented relationship, 29,34,38,44,49 (d) digital patient education and support [28][29][30][31][32]35,36,38,39,41,43,44,[48][49][50] and (e) implementing digital health (Table 3).28,34,35,42,49,51 Developing skills for information technology comprises three sub-categories: improving HCPs' skills for using digital technologies, 33,41 accessing digital resources 37,42,43,46,51 and assessing digital health information. 43,47Using digital technologies includes learning basic operational skills for digital equipment, such as videoconferencing, 41 as well as assessing and developing computer skills 33 : All physicians and health staff participating in VC and the tele oncology service should undergo formal competency training in communication skills, basic operational skills for VC equipment and cultural awareness. 41cessing digital resources includes assisting patients to navigate digital health 43 and HCPs adopting new technologies such as artificial intelligence in cancer care. 42,51It also includes ways to remind HCPs about updated digital guidelines 37 and Internet addresses, 47 as well as enhancing HCPs' awareness of institutional e-resources. 46Assessing digital health information includes providing HCPs information about the content and reliability of cancer-related websites 47 and guiding their choices as to appropriate and safe digital resources and systems. 43eveloping skills for ethical practice comprises two subcategories: protecting patients' privacy 28,30 and ensuring confidentiality. 28,30,41,50Protecting privacy was a concern in only 6% (n = 13) of the HCPs. 30Ensuring confidentiality includes accessing patients' information with their consent, 50 participation of a third person in a digital appointment 41 and the confidentiality of conversations 28 : It was often difficult to have confidential conversations on a telehealth visit conducted in a shared, tight clinic space.Nurses described colleagues' talking in the background … team members continuously entering and leaving the clinic space while they were trying to focus during a telehealth encounter. 28veloping skills for creating a human oriented relationship comprises two sub-categories: building rapport 30,32,34 and delivering difficult news. 29,44,48Building rapport includes developing skills to establish a relationship, 34 creating an emotional connection with patients 32 and maintaining a rapport 30 : … many providers reported difficulties connecting with patients or concerns regarding their ability to forge or maintain a robust provider-patient relationship. 32livering difficult news comprises two sub-categories: showing support 29 and responding to patients' emotions. 44,48howing support includes replacing physical touch and expressing empathy when telling difficult news digitally. 29Responding to patients' emotions includes dealing with patients' emotional reactions, for example, when they are angry or scared, 48 responding verbally to patients' emotional cues, verbalising empathy 44 and legitimising patients' concerns 44 : Future communication skills training programs for telephone-based supportive care needs to focus on responding verbally to patient emotional cues and verballing expressing empathy by health professionals. 44veloping skills for digital patient education and support comprises five sub-categories: providing e-counselling, 36 individualising education, 35,38,43,48,49 digital interaction, 28,29,34,38,39,41,44,49 obtaining necessary information 41 and ensuring patients' understanding 38,44,[48][49][50] .Improving skills for providing e-counselling is based on the assessment that most HCPs (n = 120, 88%) have deficiencies in these skills. 36Individualising education focuses on determining what type of appointment will best serve the patient for each encounter 35,38,43,49 and tailoring information for patients' characteristics. 48igital interaction includes using different digital media in communication. 29It also includes having necessary communication skills 29,41,49 and keeping nuances during digital communication, as digital appointments are often more factual, shorter and with fewer nuances compared to in-person appointments. 49In addition, it includes preserving the human component in interaction, 38 showing facial expressions, 29,44,49 and being present with a caring tone of voice and guidance 34 : Given the significance of empathy and support that patient experience in the cancer centers, attention to preserving the humanistic aspects of cancer care should be at the forefront of this virtual endeavour. 38taining necessary information during the digital appointments includes receiving accurate information 39 as well as reading patients' reaction to the information provided. 49urthermore, it includes skills to assess patients' condition 28,38 and perform physical examinations virtually. 30,32ocumenting each digital appointment is important. 41nsuring patients' understanding includes supporting patients to be prepared for the digital appointment, 49 presenting health information in a structured way, managing information, 48 and avoiding misinterpretations. 50In addition, it includes focusing on interview techniques with open-ended questions, 44 encouraging patients to ask questions 38,49 and checking patients' understanding during digital appointments 44 : The low number of utterances… and checking patient understanding… confirms the need for skills training to specifically assess clarification of patient understanding. 44veloping skills for implementing digital health comprises two sub-categories: creating a standard digital health policy 28,34,49 and implementing digital health guidelines. 35,42,51Creating a standard digital health policy includes updating institution practices on digital health 28 and defining the factors that constitute a good digital appointment. 34,49Skills for implementing digital health guidelines includes ensuring safety on new digital technologies such as artificial intelligence and developing ethical frameworks of new digital technologies to be applied in clinical practice. 51In addition, it includes creating frameworks for the development, adoption and regulation of AI technologies in healthcare, 42 complying with the law 51 and ensuring that the guidelines are person-centred. 35

Discussion
This systematic review produced a synthesis of digital skills of HCPs in cancer care divided into three areas, that is, the required and existing digital skills and the development areas of these skills.Existing and required digital skills of HCPs working in cancer care are a broad skillset covering skills for information technology, ethical practice, creating a human-oriented relationship and digital education and support.The studies were mainly conducted in recent five years, which is understandable considering the topic.According to the findings, the level of HCPs' existing digital skills was not systematically assessed by the professionals themselves or others involved.Due to the digital transformation in cancer care, there is an emerging need for research on HCPs' digital skills.Most of the studies showed good internal validity and decent quality.However, they were not specifically designed to study HCPs ́digital skills but rather, HCPs' experiences related to digitalisation and its effects on care delivery.Only four studies addressed the digital skills in more detail 33,36,42,46 ; however, one of them was designed to evaluate HCPs' knowledge of institutional e-resources 46 with fair study quality.Three other studies designed to explore HCPs' needs to improve their information technology skills, 33 its current use, perceptions of AI 42 or training needs for conducting e-counselling 36 showed lower methodological quality and the results should thus be viewed with caution.

Required and existing digital skills of HCPs in cancer care
In previous literature, digital skills of HCPs in cancer care were looked at from the perspective of requirements or existing skills.None of the previous studies had compared the required and existing skills or assessed the level of these skills.Both the required and the existing skills had the same main categories that were related to information technology, ethical practice, human-oriented relationship and patient education and support.Some of the content in the main and sub-categories may seem overlapping because we have tried to express their core content in the areas of related content.1]13 In information technology, a study related to the required skills for information technology, that is, finding and assessing information from the Internet, was published almost 20 years ago, 31 and the requirements are likely to be different today.In recent years, requirements in skills related to digital technology have focused on preparing digital appointments, perhaps due to their strong increase in cancer care.HCPs have been required to have basic technical skills to produce digital cancer care services, as also reported in previous studies 12,15,19 and digital skills frameworks. 11In terms of existing skills, HCPs in cancer care perceived having skills to use computers and search and assess online information more than ten years ago. 31,33owever, a recent study by Jarva et al. (2022) from various healthcare settings reported lack of technical skills related to software or technical equipment. 19Since the use of digital technology has increased rapidly in cancer care, technical skills need to be updated accordingly to deliver quality healthcare, as outlined by WHO. 4 Skills and educational needs can vary considerably between HCPs, 20 which is why assessment of actual skills and focusing education on deficiencies of these skills is needed.
In ethical practice, the required skills focused on consent to and privacy during digital appointment.This is in line with digital skills' frameworks related to safe and appropriate information delivery. 12Privacy concern is relevant since digital appointments are often held in patients' home environment, which may compromise privacy.In previous studies, privacy has been related to digital health data within services, such as whom the health information is shared. 52Previously, patient consent has been related to users' right to determine whether or how their personal data is collected, used or shared. 53In terms of existing skills, HCPs in cancer care were not concerned with confidentiality and privacy during digital appointments, although the result does not tell us about real skills to protect patients' privacy.Research on HCPs' existing digital skills for ethical practice in cancer care is lacking, although ethical values are essential for HCPs. 54herefore, the skills need to be explored further from the perspectives of privacy, confidentiality and consent.
In human-oriented relationship, the required skills were related to a person-centred approach, rapport and including patients' preference in recently published studies. 32,34,35,43,45This is in line with digital skills framework emphasising communication and collaboration in digital skills. 11The fear of the patient-HCP relationship deteriorating due to digital technology has been addressed in previous studies, 18,19,52 indicating that the relationship is seen as uniquely important in cancer care.In individualised care, HCPs need to evaluate whether digital health services are appropriate for the patient's situation 19 ; thus, knowing the patient well when making decisions about a digital appointment could enhance individualised cancer care.In terms of existing skills, the only skill reported within human-oriented relationship was building rapport.Some nurses felt that bedside manner can easily be adapted in the digital environment. 35It means active listening, connecting with the patients' story and exploring emotional cues. 55Furthermore, patients felt that HCPs had skills to establish a good relationship and communicate in a respectful and supportive way digitally. 34ue to lack of physical presence, non-verbal communication through camera may enhance digital communication. 20Identifying non-verbal communication and training these skills in the digital environment could support a deeper connection with the patient.In the included studies, skills for individualised, person-centred care were not assessed, although they are essential aspects in the care of people with cancer.
In digital education and support, the required skills entailed ensuring patients' understanding 45,49 whereas individual approach in education was not reported as required skills of HCPs.In terms of existing skills, ensuring patients' understanding was not reported; instead, the skills focused on digital interaction and support.HCPs in cancer care perceived digital interaction to be as easy and effective as in-person interaction, and some of them were able to express themselves emotionally as well. 29,30Assessing these skills could benefit the identifying of possible gaps in existing skills in providing support digitally.

Development areas on digital skills of HCPs in cancer care
Several development areas in HCPs digital skills were identified.Studies on development areas in the skills for information technology were published about ten years ago in Australia and USA, 33,41,47 meaning that the data need to be updated.The need for skills development continues to focus on technical competence, but the emphasis is more on assessing the reliability of information sources and accessing digital sources such as artificial intelligence globally. 42,51Jarva et al. 19 have stated that using digital health requires skills for finding the correct information but also media literacy to critically evaluate the available information.The need of developing HCPs' information technology skills has been addressed in previous studies 19,56 and digital skills framework, 11 as well.
In ethical practice, the development area was related to privacy and confidentiality during digital appointments.These studies were mostly conducted during the last few years in the USA, Australia and the United Kingdom. 28,30,41,50Further research is needed on ethical skills in digital cancer care to ensure its continued use in the future.In creating a human-oriented relationship, the development areas focused on building rapport and expressing empathy.Today, HCPs may lack skills to establish an emotional connection with patients and to maintain rapport digitally. 30,32Previously, this has been a challenge from both patients' and HCPs' perspective. 19,20,52Offering continuing education and opportunities to practice skills for human-oriented relationship digitally could enhance the skills for building rapport in cancer care.In delivering difficult news, the development area was focused on responding patients' emotions and providing comfort without touching. 29,44,48Careful preparation of such a delicate situation and training these skills in clinical settings is needed.HCPs' skills for delivering difficult news digitally for people with cancer have not been reported in previous studies.This may be connected to HCPs' preference to deliver difficult news in-person.Continuing education and careful preparation are needed to further develop these skills digitally as in-person appointments are not always possible.
In patient education and support, there were many development areas, the focus being on digital communication skills, which have been studied globally over the years, 41,49,50 and especially on non-verbal communication skills, 29,44,49 maybe due to the increasing number of digital appointments in cancer care.In this area, a study reporting lack of skills to conduct e-counselling was topical ten years ago, 36 which means that findings need to be considered with caution.Studies addressing ensuring patients' understanding and encouraging patient participation have also been published during the last decade, 29,38,44,49 indicating global interest in the matter.In digital education and support, the development areas focused on digital interaction and obtaining necessary information.Skills for providing e-counselling was a current area of skills about ten years ago 36 and it is necessary to update the level of these skills.Studies addressing patients' understanding and encouraging patient participation have also been published during the last decade, which indicates global interest in the issue. 29,38,44,49One development area was assessing patients' condition remotely, which has been reported in recent years. 28,30,32,38Inability to perform a hands-on physical examination digitally requires new skills of HCPs. 18,19It could be useful to innovate, together with the patients, how to replace a physical examination at a digital appointment.An important development area is checking patients' understanding of the information provided during the digital appointment.Given that misunderstandings occur in the digital environment, 50 practising skills to ensure patients' understanding could enhance patients' understanding of the information provided.
In implementing digital health, research conducted in Europe and Australia 42,51 demonstrates that HCPs can play a significant role in implementing digital services to cancer care practice.Creating a standard policy and introducing guidelines for digital cancer care services were the main development areas in implementing digital health.Those delivering digital cancer care need to be aware of state laws and regulations that govern digital health practice, 18 especially when implementing new technologies such as artificial intelligence.Legal concerns related to the use of artificial intelligence in cancer care include governance, liability and accuracy. 57Digital health ethic codes, on the other hand, focus on the establishment of the principles such as quality, privacy and informed consent among digital services. 17,53These recommendations and guidelines are important to implement in cancer care to enhance HCPs' digital skills.

Conclusion
This systematic review provides a novel synthesis of the required and existing digital skills of HCPs in cancer care, as well as the development areas of these skills.Both requirements and existing skills were identified in the literature.There are no, however, studies comparing the required and existing skills which could give also future development areas.Therefore, numerous development areas exist, with emphasis on using digital health technology in communication and education and creating an emotional connection with the patient.These skills are needed to ensure successful deployment of digital technologies in cancer care.In clinical practice, continuing education, considering both existing skills of HCPs and clinical requirements, is needed for the further development of these skills.The findings of this review can be used in development activities and research in this field.The required digital skills need clarification related to digital patient education and delivering difficult news.Studies assessing HCPs' existing digital skills in cancer care are scarce, especially related to ethical practice and patient education.Therefore, quality studies assessing these skills with valid instruments are needed.

Strengths and limitations
The strength of this review is that it provides a comprehensive synthesis of HCPs' digital skills in cancer care, identifying both skills that are required, skills that already exist and skills that need to be developed.We also used several databases without time limit, applying along historical perspective.Another strength is that good scientific practice was followed during the research process.The data selection, extraction and analysis process were conducted independently by the authors and confirmed by the research group. 58here are also limitations in the review.The first one has to do with the focus of the studies analysed: in the studies, digital skills were mainly described, not assessed.Moreover, in some cases, data was analysed relying on interpretation of the researchers, which might pose a risk to the validity of the results. 25No valid tools for assessing the digital skills were identifiable in the literature.The second limitation has to do with the concept of skill, which was described as an independent concept or as part of digital competence, with overlapping between these two concepts.In most of the earlier studies, skill is part of competence, but also an independent concept.Thus, in future studies it would be relevant to clarify this conceptual discrepancy; the problem is, however, that these concepts are not clearly defined in the literature.The third limitation has to do with the nature of the studies included: their methodological quality was not very high, and this clearly limits the generalisation of the results.Thus, the results of this review can be seen as indicating thoughts for future developments.

Implications for practice, policy and research
The results of the review have several implications.In practice, these implications have to do with existing digital skills.These are skills that professionals can be assumed to have, and practice can rely on them.There are, however, many skills still that require development, which must be considered in clinical practice and in new service fields for patients with cancer, for example, by creating a human-oriented relationship and ensuring patient understanding digitally.To secure high-level ethical practice, issues such as patients' privacy and confidentiality need to be considered during digital appointments in cancer care.This review indicates the implementation of ethical and practical guidelines to support digital cancer care.Assessment of HCPs' actual skills and educational needs could further enhance the use of digital technologies in cancer care; thus, development and validation of instruments to assess digital skills of HCPs in cancer care are also implications for future research.

Figure 1 .
Figure 1.PRISMA flow chart for the study search and selection process.22 survey identified a need to improve nurses computer proficiency.Post-intervention survey found that 78% of the nurses improved work-based computer skills and 78% improved comfort level.The intervention improved RN proficiency in finding items and overall computer skills and comfort level.Patients: 75% female, 25% male.Caregivers 75% female, 25% male HCPs' communication style during the telehealth affects patients' experiences.If HCPs' tone and attitude lacks empathy, patients may feel unwelcome to share their symptoms.Understating symptoms makes patients and caregivers feel rejected and undermines trust in both the HCPs and the healthcare system.When HCPs use caring communication, show professional competence and engage supportively, it fosters trust, build relationships and enhance the sense of being cared for.8/10 Karera et al.50 Uganda 2022 (a) To understand HCPs' views and perceptions of the use of mHealth as part of palliative care delivery.(b) To explore HCPs' perceived role in mHealth in palliative cancer care, the challenges associated with its use and how it might support the advancement of palliative cancer care (a) Qualitative design, supra-analysis (b) Semi-structured interviews (c) Thematic analysis (a) HCPs (n = 20); 10 nurses, 6 physicians, 2 social workers, a counsellor and clinical officer.(b) 75% female, 25% male Challenges in use of mHealth: Misunderstandings during mHealth communication leads to misinterpretations in patients, HCPs and care givers; confidentiality; patients' information is accessed without their knowledge or consent in instances where mobile phones are shared between households.mHealth mobile applications should be password-protected.

4 / 10
Stuij et al.48 Netherlands 2018 (a) To uncover the learning needs of oncological healthcare providers related to information provision.(b) To explore training preferences of oncological healthcare providers in the context of clinical practice with respect to a new digital training tool.nurse specialists (c) 62.5% female, 37.5% male Themes related to HCPs' learning needs in digital information provision were (a) tailoring information according to patients' situation and needs, (b) structuring information and (c) dealing with emotions.

Table 1 .
Eligibility criteria of included studies.

Table 2 .
Study characteristics (n

Table 3 .
Study findings related to digital skills.